Specialists not infrequently encounter an inflammatory skin disease such as rosacea. Despite the prevalence, the disease’s pathogenesis has not been fully studied. It is considered that congenital dysregulation of the immune and neurovascular systems plays a major role. A number of topical and systemic agents, one of which is metronidazole, is applied for rosacea treatment. This drug has been used for many decades in this disease, but the mechanism of its action is unclear, that was the reason for numerous studies. Metronidazole is an antibiotic widely used in many diseases due to its antibacterial and antiprotozoal properties. But it is assumed that its high effectiveness in rosacea is caused by anti-inflammatory action. Thus, a number of studies have shown that metronidazole contributes to the reduction of inflammation-related interleukins. It is also known about its antioxidant properties. Considering the vascular changes in rosacea, it is interesting that metronidazole participates in blocking of leukocyte rotation rate reduction and leukocyte adhesion/emigration increase caused by the impact of leukotriene on venules. Due to the combination of anti-inflammatory and antibacterial properties, metronidazole helps to cope with clinical manifestations of both erythematotelangiectatic and papulopustular forms of rosacea. This is reflected in many clinical guidelines on rosacea therapy — American and some European. Topical metronidazole is recommended for all forms of the disease except hypertrophic. Cream-based drugs should be preferred because they are better tolerated by patients, cause less discomfort and, as studies show, patients, who use metronidazole in the form of a cream, demonstrate a higher satisfaction with therapy compared to other topical agents.